Long-term Outcomes Associated With Total Arterial Revascularization vs Non-Total Arterial Revascularization

Long Term Survival Benefits of Different Conduits Used in Coronary Artery Bypass Graft Surgery- A Single Institutional Practice Over 20 Years

Objective

This study determined hazard factors and long-term survival rate of total arterial coronary artery bypass graft surgery over 20 years in an extensively large, population-based cohort.

Methods

A total of 2979 patients who underwent isolated CABG from April 1999 to March 2020 were studied in 4 groups- Group-A (bilateral internal mammary artery ± radial artery), Group-B (single internal mammary artery + radial artery ± saphenous vein), Group-C (single internal mammary artery ± saphenous vein; no radial artery), and Group-D (radial artery ± saphenous vein; no internal mammary artery). The study endpoints analysed the correlation between the number and types of grafts with the survival time following isolated CABG surgery.

Results

The total arterial revascularization (Group A) group had an admirable mean long-term survival of ~19 years, compared to 18.6 years (Group B), 15.86 years (Group C), and 10.99 years (Group D). A Kaplan-Meier curve demonstrated confidence interval (CI) for study groups- (95% CI 18.33-19.94), (95% CI 18.14-19.06), (95% CI 15.40-16.32), and (95% CI 9.61-12.38) in Group A, B, C, D respectively. In the Holm-Sidak method analysis, significant associations existed between the number of arterial grafts and the long-term outcome. A statistically significant (P≤0.05) long-term survival advantage for arterial grafting was demonstrated, especially total arterial revascularisation over all other combinations except single internal mammary artery + radial artery grafting.

Conclusion

In this series, over 20 years, total arterial CABG use has excellent long-term survival, achieving complete myocardial revascularisation. There is no significant difference between the BIMA group and SIMA with radial artery. However, there is a reduced survival with decreased use of arterial conduits.

Sex differences in long-term survival after total arterial coronary artery bypass grafting

OBJECTIVES

It is uncertain if the evidence on improved long-term survival of total arterial coronary artery bypass grafting applies to female patients. This study aims to compare the long-term survival outcomes of using total arterial revascularization (TAR) versus at least 1 saphenous vein graft separately for men and women.

METHODS

This retrospective analysis of the Australian and New Zealand Society of Cardiac-Thoracic Surgical Database had administrative linkage to the National Death Index. We identified all patients undergoing primary isolated coronary bypass from June 2001 to January 2020 inclusive. Following sex stratification, propensity score matching with 36 variables and Cox proportional hazard regression were used to facilitate adjusted comparisons. A Cox interaction-term analysis was performed to investigate the impact of sex on TAR survival benefit. The primary outcome was all-cause mortality.

RESULTS

Of the 69 624 eligible patients receiving at least 2 grafts, 13 019 (18.7%) were female patients. Matching generated 14 951 male and 3530 female pairs. Compared to vein-dependent procedures, TAR was associated with significantly reduced incidence of long-term all-cause mortality for both male (hazard ratio, 0.86; 95% confidence interval, 0.81-0.91; P < 0.001) and female (hazard ratio, 0.82; 95% confidence interval, 0.73-0.91; P < 0.001) cohorts. Interaction-term analysis indicated no significant subgroup effect from sex (P = 0.573) on the survival advantage of TAR. The treatment effect provided by TAR remained significant across most sex-stratified disease subgroups.

CONCLUSIONS

TAR, when compared to the use of at least 1 saphenous vein graft, provides comparable superior long-term survival outcomes in both females and males.

Long-Term Outcomes After Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting: Meta-Analysis of Kaplan-Meier-Derived Data

Hybrid coronary revascularization (HCR) is an alternative option to conventional coronary artery bypass grafting (CABG), but the long-term outcomes of HCR versus CABG remain unclear. We aimed to analyze the long-term outcomes after HCR and CABG for patients with multivessel coronary artery disease using meta-analysis. A systemic literature search of PubMed and EMBASE was performed from inception to March 2023. Studies reporting Kaplan-Meier curves with follow-up ≥1 year were included. The primary outcome was all-cause mortality, and the secondary outcomes were major adverse cardiac and cerebrovascular events (MACCEs) and repeat revascularization. In total, 13 studies (1 randomized controlled trial and 12 propensity-score matched observational studies) were analyzed. The mean follow-up period was 5.1 ± 3.1 years. HCR was associated with similar overall mortality (hazard ratio [HR] 1.09, 95% confidence interval [CI] 0.87 to 1.36), significantly higher incidence of MACCEs (HR 1.49, 95% CI 1.07 to 2.06), and repeat revascularization (HR 2.01, 95% CI 1.53 to 2.64) compared with CABG. In phase-specific analysis, the mortality rate was similar, and the incidence of repeat revascularization was higher in HCR regardless of phases. The incidence of MACCEs was higher in HCR during the mid-term phase (1 to 5 years), but it was similar during the long-term phase (long-term: ≥5 years). In conclusion, despite the higher incidence of MACCEs and repeat revascularization compared with CABG, HCR offered a similar long-term survival. Even longer-term follow-up and randomized controlled trials with a large population are warranted to investigate the role of HCR for multivessel coronary artery disease.

Coronary Artery Bypass Surgery: Evidence-Based Practice

Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.

Coronary Artery Bypass Surgery: Comparing the Long-Term Impact of Total Arterial Grafting With Multiarterial Plus Saphenous Vein Grafting

INTRODUCTION

This study aimed to compare the long-term outcomes in a propensity matched population receiving total arterial grafting (TAG) and multiple arterial grafts (MAG) in addition to saphenous vein graft (SVG) following multivessel coronary artery bypass grafting requiring at least three distal anastomoses.

METHODS

In this retrospective study, 655 patients from two centers met the inclusion criteria and were divided into two groups: TAG group (n = 231) and MAG + SVG group (n = 424). Propensity score matching was performed resulting in 231 pairs.

RESULTS

No significant differences were observed between both groups in terms of early outcomes. Survival probabilities at 5, 10, and 15 y were 89.1% versus 94.2%, 76.2% versus 76.1%, and 66.7% versus 69.8% in the TAG and MAG + SVG groups, respectively (hazard ratio stratified on matched pairs: 0.90; 95% confidence interval [0.45-1.77]; P = 0.754). Freedom from major adverse cardiac and cerebral events (MACCE) in the matched cohort did not show any significant difference between both groups. Probabilities at 5, 10, and 15 y were 82.7% versus 85.6%, 62.2% versus 75.3%, and 48.8% versus 59.5% in the TAG and MAG + SVG groups, respectively (hazard ratio stratified on matched pairs: 1.12; 95% confidence interval [0.65-1.92]; P = 0.679). Subgroup analyses of the matched cohort showed no significant difference between TAR with three arterial conduits compared to TAR with two arterial conduits with sequential grafting and MAG + SVG in terms of long-term survival and freedom from MACCE.

CONCLUSIONS

Multiple arterial revascularizations in addition to SVG may yield comparable long-term outcomes in terms of survival and freedom from MACCE compared to total arterial revascularization.

Bilateral Internal Thoracic Arteries Improve 10-Year Outcomes of Coronary Artery Bypass Grafting

BACKGROUND

This observational cohort study was designed by the PRIORITY (PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgery) steering committee to evaluate the 10-year follow-up outcome of bilateral internal thoracic arteries (BITA) versus single internal thoracic artery.

METHODS

The PRIORITY project was designed to evaluate long-term outcome of 2 large prospective multicenter cohort studies of coronary artery bypass grafting. Clinical data on isolated coronary artery bypass grafting were merged with administrative data to collect follow-up information. The primary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events at 10-year follow-up. Secondary endpoints were individual components of major adverse cardiac and cerebrovascular events at 10 years and surgical site complications or infections. A propensity score-based inverse probability treatment weighting (IPTW) was used to overcome the selection bias related to the observational nature of the study.

RESULTS

The study population consisted of 10,988 patients who underwent isolated coronary artery bypass grafting. BITA was used in 23.5%. The use of BITA is related to lower incidence of major adverse cardiac and cerebrovascular events at 10 years (adjusted hazard ratio [HR] 0.88, 95% CI 0.79-0.98, P < .001). BITA correlated with better 10-year survival (IPTW adjusted HR 0.87, 95% CI 0.78-1.00, P = .05), re-revascularization (IPTW adjusted HR 0.83, 95% CI 0.74-0.92, P < .001), and myocardial infarction (IPTW adjusted HR 0.86, 95% CI 0.77-0.95, P = .005) but to increased incidence of surgical site complications or infections (HR 2.12, 95% CI 1.39-3.24, P < .001).

CONCLUSIONS

In propensity-matched patients, use of BITA was associated with improved 10-year survival, freedom from repeat revascularization, and myocardial infarction but also higher incidence of surgical site complications.

Challenge in Predicting Persistence to P2Y12 Inhibitors: A Perspective From the ARTEMIS Trial

Background Premature discontinuation of P2Y12 inhibitor therapy has been associated with adverse cardiac events, which might be preventable by improving medication persistence. Current risk models have limited ability to predict patients at risk of P2Y12 inhibitor nonpersistence. Methods and Results ARTEMIS (Affordability and Real-World Antiplatelet Treatment Effectiveness after Myocardial Infarction Study) was a randomized, controlled trial testing the impact of a copayment assistance intervention on P2Y12 inhibitor persistence and outcomes. Among 6212 patients post myocardial infarction with a planned 1-year course of P2Y12 inhibitor therapy, nonpersistence was defined as a gap in P2Y12 inhibitor filled >30 days by pharmacy fill data. We developed a predictive model for 1-year P2Y12 inhibitor nonpersistence among patients randomized to usual care. P2Y12 inhibitor nonpersistence rates were 23.8% (95% CI, 22.7%-24.8%) at 30 days and 47.9% (46.6%-49.1%) at 1 year; the majority of these patients had in-hospital percutaneous coronary intervention. Patients who received the copayment assistance intervention had nonpersistence rates of 22.0% (20.7%-23.3%) at 30 days and 45.3% (43.8%-46.9%) at 1 year. A 53-variable multivariable model predicting 1-year persistence had a C-index of 0.63 (optimism-corrected C-index 0.58). Model discrimination did not improve with inclusion of patient-reported perceptions about disease, medication-taking beliefs, and prior medication-filling behavior in addition to demographic and medical history data (C-index 0.62). Conclusions Despite addition of patient-reported variables, models predicting persistence with P2Y12 inhibitor therapy performed poorly, thereby suggesting the need for continued patient and clinician education on the importance of P2Y12 inhibitor therapy after acute myocardial infarction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02406677.

Survival and Independent Predictors of Mortality Following Coronary Artery Bypass Graft Surgery in a Single-Unit Practice in the United Kingdom Over 20 Years

BACKGROUND

 The types of graft conduits and surgical techniques may impact the long-term outcomes of patients after coronary artery bypass graft (CABG) revascularization. This study observed a long-term survival rate following CABG surgery over 20 years in the United Kingdom.

METHODS

 A total of 2979 isolated CABG patients were studied from 1999 to 2020, and postoperative data were obtained from the hospital-recorded mortality by the data quality team of the information department. Postdischarge survival was estimated using the Kaplan-Meier method, and statistical significance was obtained with log-rank tests and the Gehan-Breslow test, and the Holm-Sidak method was used for multiple pairwise comparisons.

RESULTS

 The study observed male predominance (80%), and the median age was statistically significant (P <0.001) among the groups, 66 years (interquartile range 58-73) and 72 years (interquartile range 66-78) in survivor and non-survivor groups, respectively. In the Holm-Sidak method analysis, the best survival rate (mean 18.7 years) was observed in the total arterial group with significantly decreased survival for the mixed arterial and venous group (mean 16.12 years) and only the vein group (10.44 years). The Cox regression model observed that the New York Heart Association (NYHA) class III-IV (HR 1.57), chest re-exploration (HR 2.14), preoperative dialysis (HR 3.13), and redo surgery (HR 3.04) were potential predictors of the postoperative mortality (P ≤0.05).

CONCLUSION

 In our series over 20 years, albeit off-pump and on-pump CABG observed similar survival rates, the total arterial myocardial revascularization population has significantly better long-term survival benefits.

Late Clinical Outcomes of Total Arterial Revascularization or Multiple Arterial Grafting Compared to Conventional Single Arterial with Saphenous Vein Grafting for Coronary Surgery

Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2-5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.

Characteristics of Radial Artery Coronary Bypass Graft Failure and Outcomes Following Subsequent Percutaneous Coronary Intervention

BACKGROUND

When patients with prior coronary artery bypass grafting (CABG) undergo percutaneous coronary intervention (PCI), targeting the native vessel is preferred. Studies informing such recommendations are based predominantly on saphenous vein graft (SVG) PCI. There are few data regarding arterial graft intervention, particularly to a radial artery (RA) graft.

OBJECTIVES

The aim of this study was to report the characteristics of arterial graft stenoses and evaluate the feasibility of RA PCI.

METHODS

This study included 2,780 consecutive patients with prior CABG undergoing PCI between 2005 and 2018 who were prospectively enrolled in the MIG (Melbourne Interventional Group) registry. Data were stratified by PCI target vessel. RA graft PCI was compared with both native vessel (native PCI) and SVG PCI. Internal mammary graft PCI data were reported. The primary outcome was 3-year mortality.

RESULTS

Overall, 1,928 patients (69.4%) underwent native PCI, 716 (25.6%) SVG PCI, 86 (3.1%) RA PCI, and 50 (1.8%) internal mammary graft PCI. Compared with SVG PCI, the RA PCI cohort presented earlier after CABG, less frequently had acute coronary syndrome, and more commonly had ostial or distal anastomosis intervention (P < 0.005 for all). Compared with patients who underwent native PCI, those who underwent RA PCI were more likely to have diabetes and peripheral vascular disease (P < 0.001 for both) and to present with non-ST-segment elevation myocardial infarction (P = 0.010). The RA PCI group had no perforations or in-hospital myocardial infarctions, though no significant difference was found in periprocedural outcomes compared with either native or SVG PCI. No differences were found between RA PCI and either native or SVG PCI in 30-day outcomes or 3-year mortality.

CONCLUSIONS

Presenting and lesion characteristics differed between patients undergoing arterial compared with SVG PCI, implying a varied pathogenesis of graft stenosis. RA PCI appears feasible, safe, and where anatomically suitable, may be a viable alternative to native PCI.

Coronary Artery Bypass With Multiarterial Grafting vs Percutaneous Coronary Intervention

BACKGROUND

Data comparing patients who undergo multiarterial grafting during coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) in patients with multivessel coronary disease are scarce. This study addresses the relevance of using multiple arterial conduits vs PCI for appropriate patients.

METHODS

This retrospective study included all patients with coronary artery disease who underwent CABG with multiple arterial conduits or PCI. Propensity score matching was performed for baseline characteristics. Kaplan-Meier estimates, cumulative incidence, and freedom from major adverse cardiac and cerebrovascular events (MACCE) curves were performed.

RESULTS

The total patient population consisted of 3648 patients from 2011 to 2018 divided into 902 CABG patients and 2746 PCI patients. Patients were propensity matched (PCI, n = 838; CABG, n = 838). In the CABG cohort the left internal mammary artery was used in 837 patients (99.9%), the right internal mammary artery in 770 patients (92%), and radial arteries in 108 patients (12.9%). Patients in the PCI cohort had significantly higher 30-day mortality (24 [2.9%] vs 7 [0.8%], P < .01). Survival over follow-up (median, 4.9 years; range, 3.3-6.8) was better for the CABG cohort (730 [87.1%] vs 625 [74.6%], P < .01). Patients in the CABG cohort had greater freedom from MACCE (607 [72.4%] vs 339 [40.5%], P < .01). Cox multivariable regression showed that patients who underwent CABG had a significantly reduced risk of mortality (hazard ratio, 0.49; 95% confidence interval, 0.39-0.61; P < .01) and of MACCE (hazard ratio, 0.33; 95% confidence interval, 0.28-0.38; P < .01).

CONCLUSIONS

Patients with coronary artery disease who undergo CABG with multiple arterial conduits have significantly fewer major adverse events, improved survival, and reduced hospital readmissions.

Left Internal Mammary Artery as an Endocrine Organ: Insights Into Graft Biology and Long-term Impact Following Coronary Artery Bypass Grafting

The left internal mammary artery (LIMA) is considered the criterion standard vessel for use in coronary artery bypass grafting. In recent decades, countless studies have documented its superiority over other arterial and venous coronary artery bypass grafting conduits, although the full mechanisms for this superiority remain unknown. A growing body of literature has unveiled the importance of extracellular vesicles known as exosomes in cardiovascular signaling and various pathologic states. In this review, we briefly compare the clinical longevity of the LIMA relative to other conduits, explore the effects of varying grafting techniques on clinical and angiographic outcomes, and provide physiologic insights into graft function on a cellular and molecular level. Finally, we explore exosome signaling as it pertains to atherosclerosis in support of the LIMA as an "endocrine organ."

Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients

OBJECTIVES

To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD).

BACKGROUND

HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources.

METHODS

Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE).

RESULTS

Fourteen studies (12 observational studies and 2 randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios [OR]: 1.55; 95% confidence interval [CI]: 0.92-2.62; I²  = 83.0%) and long-term MACCE (OR: 0.97; 95% CI: 0.47-2.01; I²  = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95% CI: 0.25-0.51; I²  = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95% CI: -2.60 to -1.47; I²  = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95% CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95% CI: 1.03-2.20; I²  = 18%) over a follow-up duration of 29.14 ± 21.75 months.

CONCLUSION

This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.

Prior percutaneous coronary intervention and outcomes in patients after coronary artery bypass grafting: a meta-analysis of 308,284 patients

Background:

The association between prior percutaneous coronary intervention (PCI) and prognosis after coronary artery bypass grafting (CABG) remains uncertain. We aimed to evaluate the aforementioned association in a meta-analysis.

Methods:

PubMed, Cochrane’s Library, and Embase databases were searched for potential studies. A random-effects model was used for the meta-analysis. Meta-regression was performed to evaluate the influence of study characteristics on the outcomes.

Results:

Thirty-six follow-up studies with 308,284 patients were included, and 40,892 (13.3%) patients had prior PCI. Pooled results showed that prior PCI was associated with higher risks of early (in-hospital or within 1 month) all-cause mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 1.11–1.44, p = 0.003; I² = 64%] and major adverse cardiovascular events (MACEs; OR: 1.36, 95% CI: 1.12–1.66, p = 0.002, I² = 79%), but not with late (follow-up durations from 1 to 13 years) mortality (OR: 1.03, 95% CI: 0.95–1.13, p = 0.44, I² = 46%) or MACEs (OR: 1.03, 95% CI: 0.97–1.09, p = 0.38, I² = 0%). Meta-regression showed that the study characteristics of patient number, age, sex, diabetic status, and proportion of patients with prior PCI did not affect the outcomes. Sensitivity analyses limited to multivariate studies excluding patients with acute PCI failure showed similar results (early mortality, OR: 1.25, p = 0.003; early MACE, OR: 1.50, p = 0.001; late mortality, OR: 1.03, p = 0.70).

Conclusion:

The current evidence, mostly from retrospective observational studies, suggests that prior PCI is related to poor early clinical outcomes, but not to late clinical outcomes, after CABG.

Total arterial coronary artery bypass grafting in patients with preoperative anemia

OBJECTIVES

Blood transfusions after coronary artery bypass grafting (CABG) has been associated to adverse outcomes, especially in anemic patients. However, little is known about the influence of the modality of revascularization. Total arterial revascularization (TAR) was shown to reduce postoperative transfusion when compared to saphenous vein-based (SV)-CABG (LIMA plus one/more SV grafts). We, therefore, aimed to investigate the impact of TAR-CABG versus SV-CABG on blood products use and perioperative outcomes in patients with preoperative anemia, normally at higher risk for postoperative transfusions.

METHODS

From a cohort of 936 patients with mild preoperative anemia undergoing primary elective on-pump CABG, 166 matched pairs of patients undergoing either TAR- or SV-CABG were obtained. Anemia was defined as hemoglobin level <13 g/dl for men and <12 g/dl for women. The primary endpoint was the evaluation of red packed cells (RPC) use over the entire hospital stay.

RESULTS

TAR patients showed significantly reduced RPC usage compared with SV (mean difference 0.45 units). TAR patients had a reduced intubation time (mean difference 7.6 h) and were discharged 1.24 days earlier than SV patients. Pneumonia and acute kidney injury were doubled among SV patients. Adjusted regression showed that TAR technique is a predictor of reduced RPC unit use regardless of age and EuroSCORE II (odds ratio: 0.63, p < .01).

CONCLUSION

Patients with preoperative anemia might benefit from TAR regardless of age or calculated operative risk. TAR-CABG was associated to reduced postoperative use of blood products and postoperative length of stay in comparison with SV-CABG in this subset of patients.

Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization

Patients who have undergone coronary artery bypass graft (CABG) surgery are susceptible to bypass graft failure and progression of native coronary artery disease. Although the saphenous vein graft (SVG) was traditionally the most-used conduit, arterial grafts (including the left and right internal thoracic arteries and the radial artery) have improved patency rates. However, the need for secondary revascularization remains common, and percutaneous coronary intervention (PCI) has become the most common modality of secondary revascularization after CABG surgery. Procedural characteristics and clinical outcomes differ considerably from those associated with PCI in patients without previous CABG surgery, owing to altered coronary anatomy and differences in conduit pathophysiology. In particular, SVG PCI carries an increased risk of complications, and operators are shifting their focus towards embolic protection strategies and complex native-vessel interventions, increasingly using SVGs as conduits to facilitate native-vessel PCI rather than pursuing SVG PCI. In this Review, we discuss the differences in conduit pathophysiology, changes in CABG surgery techniques, and the latest evidence in terms of PCI in patients with previous CABG surgery, with a particular emphasis on safety and long-term efficacy. We explore the subject of contemporary CABG surgery and subsequent percutaneous revascularization in this complex patient population.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Impact of target vessel choice on outcomes following percutaneous coronary intervention in patients with a prior coronary artery bypass graft

OBJECTIVES

To evaluate and compare characteristics and clinical outcomes of percutaneous coronary intervention (PCI) among target vessel types in patients with a prior coronary artery bypass graft (CABG) surgery.

BACKGROUND

Patients with a prior CABG often require repeat revascularization with PCI. Graft PCI has been associated with worse outcomes compared to native vessel PCI, yet the optimal PCI strategy in prior CABG patients remains unknown.

METHODS

We stratified prior CABG patients who underwent PCI at a tertiary-care center between 2009 and 2017 by target vessel type: native vessel, venous graft, and arterial graft. The primary outcome of major adverse cardiac events (MACE) was a composite of all-cause death, myocardial infarction, stent thrombosis, or target vessel revascularization up to 1 year post-PCI.

RESULTS

Prior CABG patients (n = 3983) represented 19.5% of all PCI interventions during the study period. PCI was most frequently performed on native vessels (n = 2928, 73.5%) followed by venous (n = 883, 22.2%) and arterial grafts (n = 172, 4.3%). Procedural success and complications were similar among the groups; however, slow- and no-reflow phenomenon was more common in venous graft PCI compared to native vessel PCI (OR 4.78; 95% CI 2.56-8.95; p < 0.001). At 1 year, there were no significant differences in MACE or in its individual components.

CONCLUSIONS

Target vessel choice did not appear to affect MACE at 1 year in a large cohort of patients with prior CABG undergoing PCI. Whether PCI of surgical grafts versus native arteries truly results in similar outcomes warrants further investigation in randomized controlled trials.

Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting?

The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.

Cardiac Surgery 2020 Reviewed

In 2020, nearly 30,000 published references appeared in the PubMed for the search term "cardiac surgery." While SARS-CoV-2 affected the number of surgical procedures, it did not affect outcomes reporting. Using the PRISMA approach, we selected relevant publications and prepared a results-oriented summary. We reviewed primarily the fields of coronary and conventional valve surgery and their overlap with interventional alternatives. The coronary field started with a discussion on trial data value and their interpretation. Registry comparisons of coronary artery bypass surgery (CABG) and percutaneous coronary intervention confirmed outcomes for severe coronary artery disease and advanced comorbidities with CABG. Multiple arterial grafting was best. In aortic valve surgery, meta-analyses of randomized trials report that transcatheter aortic valve implantation may provide a short-term advantage but long-term survival may be better with classic aortic valve replacement (AVR). Minimally invasive AVR and decellularized homografts emerged as hopeful techniques. In mitral and tricuspid valve surgery, excellent perioperative and long-term outcomes were presented for structural mitral regurgitation. For both, coronary and valve surgery, outcomes are strongly dependent on surgeon expertise. Kidney disease increases perioperative risk, but does not limit the surgical treatment effect. Finally, a cursory look is thrown on aortic, transplant, and assist-device surgery with a glimpse into the current stand of xenotransplantation. As in recent years, this article summarizes publications perceived as important by us. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide up-to-date information for decision-making and patient information.

The use of free versus in situ right internal mammary artery in coronary artery bypass grafting

INTRODUCTION

Coronary artery bypass grafting (CABG) continues to be the most commonly performed cardiac surgical procedure in the world. The use of multiarterial grafting may confer a long-term survival benefit over the use of vein grafts. However, there is a paucity of data comparing the use of in situ versus free right internal mammary artery (RIMA) in isolated CABG.

METHODS

Patients that underwent isolated CABG between 2010 and 2018 where RIMA was used in addition to a left internal mammary artery graft. Patients with prior cardiac surgery or percutaneous coronary intervention were excluded. Propensity matching was used for subanalysis. Mortality and major adverse cardiac and cerebrovascular events (MACCE) were analyzed with Kaplan-Meier survival curves and Cox multivariable regression. Heart failure-specific readmissions were assessed with cumulative incidence curves with Fine and Gray competing risk regression.

RESULTS

A total of 667 patients underwent isolated CABG. Of those, 422 had free RIMA and 245 had in situ RIMA utilized. Mortality was similar between cohorts (p = 0.199) with 5-year mortality rates of 6.6% (free) and 4.1% (in situ). MACCE was similar between cohorts, with 5-year event rates of 33.6% and 33.9% (p = 0.99). RIMA style was not a significant predictor of any outcome.

CONCLUSION

There was no difference in long-term mortality, complications, MACCE, or heart failure readmissions when comparing a contemporary cohort of patients undergoing isolated CABG utilizing RIMA as a conduit. These data may allow surgeons to consider using RIMA either as an in situ or a free conduit.

Radial artery as a second conduit gains momentum: The RAPCO trial

In coronary artery bypass grafting (CABG), the use of an internal mammary artery (IMA) to graft the left anterior descending coronary artery (LAD) improves survival and reduces the need for repeat revascularization. The other IMA, radial artery (RA), and saphenous vein (SV) have contested to complete the surgical revascularization. For that purpose, SV remains the most commonly used conduit despite current evidence in favor of arterial grafts. To determine which conduit is best for grafting the second most important coronary artery, Buxton and colleagues have recently published the long term results of their "Radial Artery Patency and Clinical Outcomes (RAPCO)" trial.

Multiple arterial conduits for multi-vessel coronary artery bypass grafting in patients with mild to moderate left ventricular systolic dysfunction: a multicenter retrospective study

Background

Advantages of multiple arterial conduits for coronary artery bypass grafting (CABG) have been reported previously. We aimed to evaluate the mid-term outcomes of multiple arterial CABG (MABG) among patients with mild to moderate left ventricular systolic dysfunction (LVSD).

Methods

This multicenter study using propensity score matching took place from January 2013 to June 2019 in Jiangsu Province and Shanghai, China, with a mean and maximum follow-up of 3.3 and 6.8 years, respectively. We included patients with mild to moderate LVSD, undergoing primary, isolated multi-vessel CABG with left internal thoracic artery. The in-hospital and mid-term outcomes of MABG versus conventional left internal thoracic artery supplemented by saphenous vein grafts (single arterial CABG) were compared. The primary end points were death from all causes and death from cardiovascular causes. The secondary end points were stroke, myocardial infarction, repeat revascularization, and a composite of all mentioned outcomes, including death from all causes (major adverse events). Sternal wound infection was included with 6 months of follow-up after surgery.

Results

243 and 676 patients were formed in MABG and single arterial CABG cohorts after matching in a 1:3 ratio. In-hospital death was not significantly different (MABG 1.6% versus single arterial CABG 2.2%, p = 0.78). After a mean (±SD) follow-up time of 3.3 ± 1.8 years, MABG was associated with lower rates of major adverse events (HR, 0.64; 95% CI, 0.44–0.94; p = 0.019), myocardial infarction (HR, 0.39; 95% CI, 0.16–0.99; p = 0.045) and repeat revascularization (HR, 0.42; 95% CI, 0.18–0.97; p = 0.034). There was no difference in the rates of death, stroke, and sternal wound infection.

Conclusions

MABG was associated with reduced mid-term rates of major adverse events and cardiovascular events and may be the procedure of choice for patients with mild to moderate LVSD requiring CABG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01463-5.

Hybrid coronary revascularization versus total arterial revascularization for the treatment of left main coronary artery disease

Background

Hybrid coronary revascularization (HCR) has a similar clinical outcome to coronary artery bypass grafting (CABG) in treating multivessel disease. However, the outcome of HCR in treating left main coronary artery (LM) disease is unclear. This study sought to compare the clinical outcome of HCR with total arterial revascularization (TAR) for treating LM disease.

Methods

Patients who underwent treatment for LM disease in our center between January 2009 and December 2019 were selected. Of these, 33 patients underwent HCR, and 70 patients underwent TAR. The primary efficacy outcome of this study was mid-term major adverse cardiac and cerebrovascular events (MACCE). The primary safety outcome was perioperative MACCE.

Results

The incidence of postoperative outcomes was comparable between the two groups after adjustment with inverse probability weighting (IPW) (P>0.05). The median follow-up time was 47 (interquartile range, 20 to 85) months. There was no significant difference in the incidence of all mid-term outcomes and the freedom of MACCE between the two groups after adjustment (P>0.05). The Cox proportional hazard model demonstrated that HCR was not a significant determinant for MACCE [hazard ratio (HR) =3.516, 95% confidence interval (CI): 0.835 to 14.813].

Conclusions

HCR may be safe and effective for the treatment of LM disease compared with TAR.

Total Arterial Coronary Bypass Graft Surgery is Associated with Better Long-Term Survival in Patients with Multivessel Coronary Artery Disease: a Systematic Review with Meta-Analysis

INTRODUCTION

The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients.

METHODS

The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed.

RESULTS

Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome.

CONCLUSION

This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

[Acute cerebral circulation impairment associated with percutaneous coronary intervention]

The article deals with generalized literature data on the current importance of the problem concerning acute cerebral ischemia occurring during percutaneous coronary interventions. Pathophysiological mechanisms of the development of acute cerebral circulation impairment are described, with their classification. Also considered are various risk factors which may cause this formidable complication, followed by describing modern methods of its surgical treatment. It is noted that the main risk factors for neurological complications appearing after revascularization of coronary arteries include age, accompanying diseases (instability of arterial pressure, diabetes mellitus, atrial fibrillation, atherorosclerotic lesions of the aorta and brachiocephalic arteries, previous stroke), as well as systolic dysfunction, leukocytosis, and a low level of cognitive function prior to operation. The development of acute cerebral circulation impairment during and after percutaneous coronary intervention is an indication for using methods of endovascular treatment. It is most appropriate to use a combination of direct percutaneous thrombectomy and a stent retriever. It is underlined in the article that removal of the thrombus form the cerebral artery is not an independent surgical procedure but rather a methodology envisaging an operation to be performed from the simplest technique to the most complicated one. As the first procedure, it is necessary to perform thrombaspiration and then, if ineffective, a second stage consisting in thrombextraction with the help of a stent retriever. Besides, in order to increase efficacy of thrombaspiration there have been worked out several techniques combining the use of direct thrombextraction and a stent retriever. Described in detail are 4 most commonly used techniques.

Multiple arterial coronary bypass grafting is associated with greater survival in women

OBJECTIVE

Multiple arterial grafting (MAG) in coronary artery bypass grafting (CABG) is associated with higher survival and freedom from major adverse cardiac and cerebrovascular events (MACCEs) in observational studies of mostly men. It is not known whether MAG is beneficial in women. Our objectives were to compare the long-term clinical outcomes of MAG versus single arterial grafting (SAG) in women undergoing CABG for multivessel disease.

METHODS

Clinical and administrative databases for Ontario, Canada, were linked to obtain all women with angiographic evidence of left main, triple or double vessel disease undergoing isolated non-emergent primary CABG from 2008 to 2019. 1:1 propensity score matching was performed. Late mortality and MACCE (composite of stroke, myocardial infarction, repeat revascularisation and death) were compared between the matched groups with a stratified log-rank test and Cox proportional-hazards model.

RESULTS

2961 and 7954 women underwent CABG with MAG and SAG, respectively, for multivessel disease. Prior to propensity-score matching, compared with SAG, those who underwent MAG were younger (66.0 vs 68.9 years) and had less comorbidities. After propensity-score matching, in 2446 well-matched pairs, there was no significant difference in 30-day mortality (1.6% vs 1.8%, p=0.43) between MAG and SAG. Over a median and maximum follow-up of 5.0 and 11.0 years, respectively, MAG was associated with greater survival (HR 0.85, 95% CI 0.75 to 0.98) and freedom from MACCE (HR 0.85, 95% CI 0.76 to 0.95).

CONCLUSIONS

MAG was associated with greater survival and freedom from MACCE and should be considered for women with good life expectancy requiring CABG.